Digestion 16: 118-127 (1977)
a-Fetoprotein Screening in Patients with Idiopathic Hemochromatosis and Liver Cirrhosis1 J.A.P. Chayvialle, P. Brissot, M.J. Pelletier, Y. Hita deNercy, R. Lambert and M. Bourel2 Inserm, U-45; Service d’Hépato-gastrocntérologie, Hôpital Edouard-Herriot, Lyon; Inserm, U-49, and Chaire de Clinique Médicale A, Hôpital Pontchaillou, Rennes
Key Words. a-Fetoprotein • Radioimmunoassay • Hemochromatosis • Hepatoma • Liver cirrhosis Abstract. The serum a-fetoprotein level was measured by radioimmunoassay in 200 patients when admitted to hospital, 63 with idiopathic hemochromatosis and 137 with liver cirrhosis. In addition, repeated controls were performed in 19 subjects of each group for a mean period of 11 months (range 3-18 months). Elevated a-fetoprotcin levels were ob served initially or during the study period in 15 patients, a malignant liver tumor being demonstrated in 12 of them. In 4 of these patients, the abnormal a-fetoprotein concentra tion was the clue to the diagnosis of an unsuspected malignant hepatoma, but in none of these cases could the tumor be resected. The present results indicate that screening the serum a-fetoprotein level may contribute to the detection of malignant hepatoma in highrisk clinical groups, but the practical interest of such screenings may keep limited until more efficient therapeutic methods are developed.
The development of a malignant hepatoma is recognized in 7—25% of pa tients with idiopathic hemochromatosis (10, 16, 29, 36). The incidence of this complication seems to be increasing (23), its occurrence being noted even after adequate iron depletion in treated patients (9, 15, 36). A malignant hepatoma is similarly observed in 3—27% of patients with liver cirrhosis (7, 12, 18, 28), the highest figures being recorded in post-hepatic cirrhosis (13, 24). Although prolonged survival has occasionally been observed in some un treated patients (11, 27), the tumor resection appears to be the most beneficial curative approach (6, 21). Because of the high rate of unoperable patients at the 1 Supported by Inserm CRL No. 74.5.079.04. J The skilful assistance of Mrs. C. Bernard is gratefully acknowledged.
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Received; December 30, 1976; accepted; April 26, 1977.
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Table I. Patients studied Diagnostic
n
Idiopathic hemochromatosis Untreated Treated Iron-depleted Liver cirrhosis Alcoholic Posthepatic Cryptogenic
63 27 18 18 137 115 8 14
Male
Female
Age range years
55
8
28-66
100
37
25-81
time of diagnosis, early detection is compulsory if significant therapeutic results are to be expected. The diagnostic value of high serum a-fetoprotein (AFP) levels in human adults with malignant hepatoma has been thoroughly documented (34, 35). After the development of sensitive detection methods (30), it has become pos sible to recognise any increase of the serum AFP level above the normal range. The present study is an attempt to detect early malignant hepatomas in patients with idiopathic hemochromatosis and liver cirrhosis by using a radioim munoassay (RIA) for the measurement of serum AFP level.
Patients and Methods The study group included 200 patients, admitted in Rennes or Lyon from December 1974 to June 1976 (table I). Idiopathic Hemochromatosis This group included 63 subjects (8 females and 55 males, age range: 28-66 years). The diagnosis of idiopathic hemochromatosis was based on (a) the usual clinical and biological criteria; (b) the chemical measurement of liver-iron concentration in biopsy specimens (3), and (c) HLA typing (32). Among the 58 patients in whom the liver was histologically controlled, 30 had advanced cirrhosis, 16 definite but nonannular fibrosis, and 12 slight or absent fibrosis. The initial AFP control was performed before any treatment in 27 subjects, during the treatment in 18 patients, and after iron depletion in the 18 remaining subjects. Serial measurmeents of the serum AFP level could be performed in 19 patients, 63 blood samples being collected during a mean period of 10.2 months (range: 3 -1 8 months).
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Cirrhosis This group included 137 patients (100 males and 37 females, age range: 25-81 years). In these subjects, liver cirrhosis was demonstrated by biopsy (83 cases), peritoneoscopy without histological control (19 cases), or after the clinical and biological symptoms in the remaining patients whose condition was too severe to allow for the above investigations.
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Cirrhosis was attributed to chronic alcohol consumption in 115 patients, previous viral hepatitis in 8 subjects, while no precise etiology was recorded in the 14 other patients. In 87 cases, the clinical picture at the first AFP control included signs of decompensated cirrhosis. Serial measurements of the serum AFP level were performed in 19 patients, 81 samples being collected during a mean follow-up period of 12.0 months (range: 5 -1 8 months). Methods Sera were kept at - 20 °C until being assayed with a RIA method previously described (8), using a highly purified preparation of AFP from fetal serum as standard (Dr. P. Sizaret, 1ARC, Lyon). In this system, the upper limit of normal in adults (mean + 3 SD) is 7.7 ng/ml, equivalent to 6.61 IU of the 72/225 Reference preparation issued by WHO. AFP concentrations above this value were considered significantly elevated.
Results Idiopathic Hemochromatosis The initial control yielded two abnormal AFP concentrations in this group (table II). In patient 1, the development of a malignant hepatoma had already been suspected because of major hepatic enlargement, jaundice, and weight loss, and was subsequently confirmed at surgery. In contrast, the condition of patient 2 after repeated plilebotomies (15 liters of blood taken in 10 months) had not led to the hypothesis of liver neoplasia. The malignant hepatic tumor, demon strated thereafter at surgery was beyond any attempt of resection (table 111). In the 61 other subjects, the initial serum AFP concentration was normal. A malignant hepatic tumor was detected in 3 of them (patients 3—5). Patient 3, a 59-year-old man, with hemochromatosis iron-depleted since 3 years, had been given irregular injections of testosterone hexahydroxybenzoate for the last 5 years (total dose: more than 7 g). The postmortem control revealed a malignant hepatoma 9 months after completing the present study. Patient 4 had been maintained iron-depleted for the last 3 years, while a persistent iron overload was still demonstrable in patient 5, in whom the phlebotomies had been inter rupted 10 months earlier after a total blood depletion of 17 liters. No histologi cal control could be obtained in these 2 subjects. Repeated AFP controls in the 16 patients with normal serum levels and no detectable tumor when initiating the study, showed no rise of the serum AFP level in any of these patients, no liver tumor being demonstrated in this group during the study period.
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Cirrhosis When entering the study, 13 of the 137 patients with liver cirrhosis had elevated AFP levels. These subjects could be segregated in 2 groups: Group 1. A malignant hepatic tumor was demonstrated in 10 subjects (8 with alcoholic and 2 with posthepatic cirrhosis), the diagnosis of malignant
Screening in Hemochromatosis and Liver Cirrhosis
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hepatoma being histologically confirmed in 7 cases. In 8 of these patients, the neoplasia had been suspected before any control of the AFP level (patients 6—13). In the 2 other subjects, the high serum AFP concentration led to the diagnosis of the liver tumor (patients 14, 15; table II). Group 2. In the three other subjects, the rise of the serum AFP level was moderate (respectively, 13, 49 and 50 ng/ml). In none of them could any hepatic or extrahepatic tumor be demonstrated. Patient Sek., with alcoholic cirrhosis and histological features of superimposed alcoholic hepatitis at the time of initial control, could be followed up for several months. Among the 124 subjects with an initially normal AFP level, 2 patients had demonstrable hepatic tumors. In the first case (patient 16), the clue to the malignant hepatoma was the histological control of a skin metastasis. In the other patient (patient 17), a malignant liver tumor was demonstrated by scanning and peritoneoscopy after severe hypoglycemic attacks (table III). No Table II. Serum AFP levels in patients with recognized liver tumors Patient No.
Age
Sex
Underlying liver disease
Serum AFP level, ng/ml initial
1 2* 3
52 52 59
M M M
4 5 6 7 8 9 10 11 12 13 14* 15* 16 17 18*
56 66 64 51 77 63 72 67 65 70 64 62 67 67 60
M M M M M M M M M M M M M M M
untreated IH treated IH iron-depleted IH (+androgens) iron-depleted IH treated IH AC PHC AC AC AC AC AC AC PHC AC AC AC AC
delay
___ 3,550 2 months 11,500 7.3 10 months
1.3 4.1 157 26,000 9,500 2,010 3,650 6,600 44,500 75,900 160 42,000 6.2 8.3 6.0
subsequent
_
20,000 28
-
-
-
-
-
4 months — -
2 months
-
19,000 -
38,500
—
-
—
-
—
1 month
-
8,200
—
-
—
-
—
6 months 8 months
-
225 815
Nature of hepatic tumor
Evolution
MH MLT
MLT MLT MH MCH MCH MLT MCH MLT MLT MH MH MH MH MLT
deceased deceased deceased (1977J deceased alive deceased deceased deceased deceased deceased deceased deceased deceased deceased deceased deceased deceased
MLT
lost
MH
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IH = Idiopathic hemochromatosis; AC = alcoholic cirrhosis; PHC = posthepatic cirrhosis; MH = malignant hepatoma; MCH = malignant cholangiohepatoma; MLT = malignant liver tumor, no histological control; + = diagnosis obtained from serum AFP level.
Table III. Clinical and investigative details of the 18 patients with liver tumor, listed as in table II Liver scan Pro thrombin time, % (N 80%)
Hepatic angiography
Macroscopy5
Pathology5
Weight loss'
Jaundice Ascites
Alkaline phosphatase mlU/ml (N 30 mlU/ml)
1
+++
+
+
135
77
2
0
0
0
25
100
filling defect displacement of tumor left lobe celiac axis + peritoneum left lobe (LT)
3
++
0
0
13
100
filling defect displacement of tumor right hepatic arteries lobe (LT) right lobe + vascular tumor
4
++
+
+
107
77
5
++
+
0
192
100
multiple filling defects
6
++
0
0
80
100
filling defect left lobe
7
++
0
+
176
100
filling defect abnormal left left lobe hepatic artery
multiple hemorrhagic nodules (PS)
cholangiohepatoma (PMB)
8
+
+
+
69
52
filling defect right lobe
tumor right lobe (N)
cholangiohepatoma
filling defect displacement of irregular right lobe hepatic arteries hepatomegaly (LT)
Miscellaneous
differentiated hepatoma (WB)
differentiated hepatoma (PMB) recent hepatomegaly, hepatic murmur, death 2 days after admission recent hepatomegaly, hepatic murmur, no extrahepatic tumor found differentiated hepatoma (NB) Australia antigen +
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Patient No.
9
+++
+
+
85
77
filling defect right lobe
no extrahepatic tumor found
10
+++
0
0
55
70
filling defect right lobe
11
+++
+
+
28
60
hypervascular tumor left lobe (PS)
12
++
+
0
79
90
hypervascular tumor right lobe + hemoperitoneum (PS)
13
0
+
0
34
100
14
0
0
0
85
55
15
0
0
0
66
75
16
0
0
+
33
65
17
++
0
+
103
77
filling defect right lobe
whitish hemorrhagic areas, right lobe (PS)
18
0
0
+
37
50
filling defect hypervascular right lobe nodule right lobe
hypervascular nodule right lobe (PS)
tumor right lobe (PS)
cholangiohepatoma (PMB) hemorrhagic ascites
multiple nodules right lobe (PS)
right pleural differentiated hepatoma (NB) effusion
filling defect right lobe
no tumor seen (PS)
hepatoma (NB) Australia antigen +
filling defect right lobe
tumor right lobe (PS)
hepatoma (NB) splenorenal + hemosiderosis shunt, 1969 poorly differentiated hepatoma (skin metastasis)
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' + = 5 kg; ++ = 6 -1 0 kg; +++ = 10 kg.
1 N = Necropsy; L = laparotomy; PS = peritoneoscopy. 3 WB = Wedge biopsy: PMB = postmortem biopsy; NB = needle biopsy.
hypoglycemia; no extrahepatic tumor found
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histological control of the liver tumor could be obtained, but the search for a primary extrahepatic neoplasm was negative. Among the 19 patients followed up for several months, 17 kept a normal AFP concentration while no hepatic tumor was detected. High AFP concen trations were observed in the 2 other patients. Patient Sek. kept a persistently abnormal AFP level (between 13 and 160ng/ml), but no liver tumor could be found after various investigations, including angiography, peritoneoscopy and liver biopsy. The second patient (patient 18), a 60-year-old man with alcoholic cirrhosis had, initially, a normal AFP level. The concentration rose to 225 and 815 ng/ml, respectively, after 6 and 8 months of follow-up. A malignant hepatic tumor of the right lobe was then demonstrated by angiography and perito neoscopy, no biopsy being attempted because of the vessels on the surface. The condition of the patient deteriorated rapidly thereafter, and no resection was possible.
Because grossly increased AFP synthesis occurs in a significant number of adult patients with a malignant hepatoma, immunodiffusion methods are of value for the detection (34, 35) and the postoperative follow-up of patients with this tumor (1). These methods could be used as well for the screening of symptomless subjects, in order to detect early malignant hepatomas (17). The practical interest of such studies was, however, limited because of the lack of sensitivity of immunodiffusion. With tire more sensitive radioimmunoassay methods, high serum AFP con centrations are recorded in 70-100% of patients with malignant hepatomas (4, 8, 31), while the range of AFP levels observed in normal adult subjects is relatively narrow. In addition, AFP concentration appears to be stable with time (8, 25). Sensitive methods may thus be expected to allow for improved detection of these tumors. This was recently confirmed in two large study groups of patients with liver cirrhosis, where the control of AFP level was used alone or in conjunction with other investigative methods (19, 20, 37). However, the actual contribution of AFP screening to the detection, hence to the manage ment of malignant hepatoma in high-risk clinical groups is not fully assessed yet. The present work, though based on a relatively small number of patients, was an attempt to evaluate this contribution. In patients with idiopathic hemochromatosis or liver cirrhosis an abnormal AFP level cannot be taken as a proof for a malignant hepatoma. Elevated AFP concentrations have been reported in patients with these conditions (5, 8, 26) and no demonstrable hepatic or extrahepatic tumor at postmortem. The incidence of such variations was remarkably high in some series (14, 19). In most
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Discussion
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of these patients, the rise of AFP concentration is moderate and of relatively short duration, so that tire dynamics of the variation of the AFP level might help to differentiate the patients with malignant hepatomas from those without tumor. This, however, would result in a significant delay for the diagnosis of the tumor, if any. It thus seems that for practical purposes, any significant rise of the AFP level should instead be taken as a sign for a possible liver tumor (patient 18). In the present study, only 3 patients with liver cirrhosis had moderately high AFP concentrations and no demonstrable hepatic tumor, while none of the subjects with hemochromatosis fell in this situation. In contrast, a malignant hepatic tumor was detected in the 13 other subjects with liver cirrhosis or hemochromatosis and an increased AFP concentration. The incidence of proven malignant hepatomas in the liver cirrhosis group (5.8%) was slightly higher than the figure in the patients with hemochromatosis (3.2%). This is likely to have resulted from different screening conditions, since a number of patients with hemochromatosis were investigated through family enquiries, while most of the subjects with liver cirrhosis were in-patients admitted for clinical symptoms. Previous studies have demonstrated that a significant contribution to the diagnosis of hepatoma may result from AFP screening in high-risk clinical groups (19, 20, 37). This was confirmed in the present study, since the measurement of serum AFP level led to the recognition of an unsuspected liver tumor in 4 patients (2% of the total study group). Whether improved detection of these tumors through biological controls allows for better therapeutic results may, however, be debated at the moment. Significant results were obtained in some studies (27), while the improvement in therapy was low (17) or not indicated (19) in other studies. None of the present subjects with a malignant hepatoma detected before obvious clinical signs could benefit from a resection, because of severe underlying hepatocellular failure or neoplastic diffusion. Although the surgical management of malignant hepatoma has been clearly improved during the last years (6, 21, 22), curative resection keeps restricted to localized tumors in patients with a moderate liver cirrhosis (2, 22). Until new therapeutic methods are developed for the management of malignant hepatoma whatever the tumor spread and the degree of hepatocellular impairment, AFP screening appears to be mostly valuable for the diagnosis of localized AFP-producing tumors in patients with adequately treated idiopathic hemochromatosis or with liver cirrhosis and mild hepatocellular dysfunction.
References
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1 Alpert, E.: Starzl, T.E.; Schur, P.H., and ¡sselbacher, K.J.: Serum a-foetoprotein in hepatoma patients after liver transplantation. Gastroenterology 61: 144-148 (1971). 2 Balasegaram, M.: Management of primary liver cell carcinoma. Am. J. Surg. 130: 33-37 (1975).
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Barry. M. and Sherlock, S.: Measurement of liver-iron concentration in needle-biopsy specimens. Lancet/: 100-103 (1971). Bloomer, J.R.: Waldmann. T.A.P.; Mclntire, K.R., and Klatskin, G.: Relationship of serum a-foetoprotein to the severity and duration of illness in patients with viral hepatitis. Gastroenterology 68: 342-350 (1975). Bourreille, J.: Alpha,-foetoprotcine et maladies non cancéreuses du foie. Annls Gastro enterol. Hepatol. 7: 565-570 (1971). Brasfield, R.D.: Bowden, and McPeak, C.J.: Major hepatic resection for malignant neoplasms of the liver. Ann. Surg. 1 76: 171-177 (1972). Caroli, J.; Marcus, N.; Grynhlat, A. et Chevrel, B : Lc cancer primitif du foie sur cirrhose. A propos de 120 cas. Revue méd. Chir. mal. Foie 45: 291-298 (1970). Chayvialle, J.A.P.; Touillon, C.: Crozier, C., and Lambert, R.: Radioimmunoassay of a-foetoprotein in human serum. Clinical value in patients with liver diseases. Am. J. dig. Dis. 19: 1102-1110 (1974). Conte, M.; Bodin, F. et Conte-Marti, M.: Le traitement actuel des hemochromatoses essentielles et le pronostic des hemochromatoses (en particulier le cancer du foie). Bull. Soc. méd. Hôp. Paris 117: 945-961 (1966). Darnis, F.: Les hémochromatoses (à propos de 100 observations). Annls Biol. Clin. 30: 349-378 (1972). Davidson, A.R.; Tomlinson, S.: Caine, R. Y., and Williams, R.: The variable course of primary hepatocellular carcinoma. Br. J. Surg. 61: 349-352 (1974). Edmonson, H.A. and Steiner, P.E.: Primary carcinoma of the liver. A study of 100 cases among 48,900 necropsies. Cancer 7: 462-563 (1954). Gall, E.A.: Primary and metastatic carcinoma of the liver. Relationship to hepatic cirrhosis. Archs Path. 70: 226—232 (1960). Hadziyannis, S.; Karvountzis, G.; Manesis, E.; Gioustozi, A., and Merikas, G.: Diagnostic significance of serial a-foetoprotein (AFP) determination by radioim munoassay (RIA) in cirrhosis. Digestion 12: 267-268 (1975). Hines. C.: Davis, W.D.. and Ferrante, W.A.: Hepatoma developing in hemochromatosis in spite of adequate treatment by multiple phlebotomies. Am. J. dig. Dis. 16: 349-355 (1971). Launois, J.P.: Franc, B. et Cachin, M.: Hémochromatose idiopathique et cancer primitif du foie. Scm. Hôp. Paris 51: 1205-1212 (1975). Leblanc, L.; Tuyns. A.J., and Masseyeff, R.: Screening for primary liver cancer. The relationship between the time of appearance of a-foetoprotein in the serum and clinical symptoms in nine cases. Digestion 8: 8 -1 4 (1973). Lee. F.L.: Cirrhosis and hepatoma in alcoholics. Gut 7: 77-85 (1966). Lehmann, F.G.: Prognostic significance of alpha,-foetoprotein in liver cirrhosis. Fiveyear prospective study; in Fishman and Sell Onco-developmental gene expression, pp. 407-415 (Academic Press, New York 1976). Lehmann, F.G.: Early detection of hepatoma. A Prospective study in liver cirrhosis using passive hemagglutination and the radioimmunoassay. Ann. N.Y. Acad. Sci. 259: 196-210 (1975). Lin, T.Y.: Primary cancer of the liver. Scand. J. Gastroent., suppl 6, pp. 223-241 (1970). Lin, T. Y.: Recent advances in techniques of hepatic lobectomy and results of surgical treatment for primary carcinoma of the liver; in Popper and Schaffner Progress in liver diseases, chapt. 39, pp. 668-682 (Grune & Stratton, New York 1976). McDonald. R.A.: Cirrhosis and primary carcinoma of the liver. Changes in their occur rence at the Boston City Hospital 1897 -1954. New Engl. J. Med. 225: 1179-1183 (1965).
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J.A.P. Chayvialle, Inserm, U-45, Pavillon H Bis, Hôpital Edouard-Herriot, 69374 Lyon Cedex 2 (France)
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24 McDonald, R.A.: Primary carcinoma of the liver. A clinico-pathologic study of 108 cases. Archs intern. Med. 99: 266-279 (1957). 25 Martel, N.; Tuyns, A.J.. and Sizaret, P.: Alphafetoprotein level in normal individuals. Relative stability over time (in press). 26 Nishi, S. and Hirai, H.: Radioimmunoassay of a-foetoprotcin in hepatoma, other liver diseases and pregnancy; in Hirai and Miyaji Alpha-foetoprotein and hepatoma, pp. 79-87 (University Park Press, Baltimore 1973). 27 Okuda, K.; Fotoda, K.; Obata, H.: Hayashi, N.; Hisamitsu, T.; Tamiya, M.; Kubo, Y.; Yakushiji, F.: Nagata, E.; Jinnouchi, S., and Shimokawa, Y. Clinical observations during a relatively early stage of hepatocellular carcinoma with special reference to serum a-foetoprotein levels. Gastroenterology 69: 226—234 (1975). 28 Pequignot, H.; Etienne, J.P.; Delavierre, P. et Petite, J.P.: Cancers primitifs du foie sur cirrhose. Augmentation de fréquence et observation chez des cirrhotiques connus et suivis. Presse méd. J: 2595-2600 (1967). 29 Powell, L.W.: Mortimer, R., and Harris. O.D.: Cirrhosis of the liver. A comparative study of the four major aetiological groups. Med. J. Aust. 1: 941-950 (1971). 30 Ruoslahti, E. and Seppala, M.: Studies of carcino-fetal proteins. III. Development of a radioimmunoassay for AFP. Demonstration in serum of healthy human adults. Int. J. CancerS; 374-383 (1971). 31 Ruoslahti, E.: Seppala, M.; Vuopio, P.; Saksela, E., and Peltokallio, P .: Radioim munoassay of a-foetoprotein in primary and secondary cancer of the liver. J. natn. Cancer Inst. 49: 623-630 (1972). 32 Simon, M.; Bourel, M.: Faucher, R., and Cenetet, B.: Association of HLA-A3 and HLA-B14 antigens with idiopathic hemochromatosis. Gut 17: 332- 334 (1976). 33 Sizaret, P.: Tuyns, A.J.: Martel, N.; Jouvenceaux, A.; Levin, A.: Ong, Y. IV., and Rive, J.: Alpha-foetoprotein levels in normal males from seven ethnic groups with different hepatocellular carcinoma risks. Ann. N.Y. Acad. Sci. 259: 136-155 (1975). 34 Tatarinov, Y.S.: Content of embryo-specific a-globulin in the blood serum of human foetus, newborn and adult man in primary cancer of the liver. Vopr. med. Khirn. 11: 20-24 (1965). 35 Uriel. J.; Nechaud, B. de; Stanislawski-Birencwajg, M.; Masseyeff. R.; Quenum, C.; Loisillier, F. et Grabar, P.: Antigènes embryonnaires et cancer du foie chez l’homme; association de l’a-fœtoprotéine sérique avec l’hépatome primaire. C. r. hebd. Séanc. Acad. Sci., Paris 265: 75-85 (1967). 36 Walker, R.J. and Williams, R.: Haemochromatosis and iron overload; in Jacobs and Worwood Iron in biochemistry and medicine, pp. 589—612 (Academic Press, London 1974). 37 Weiss, W.; Dittrich, H.: Baumgartner, G.; Blazek, G.; Eder, G.; Hanak, H.; Hentschel, E.; Kahn, P.; Mastnak, C. und Urbanek, A.: Zur Früherkennung des primâren Leberkarzinoms. Wien. med. Wschr. 126: 16-22 (1976).
a-Fetoprotein Screening in Patients with Idiopathic Hemochromatosis and Liver Cirrhosis1 J.A.P. Chayvialle, P. Brissot, M.J. Pelletier, Y. Hita deNercy, R. Lambert and M. Bourel2 Inserm, U-45; Service d’Hépato-gastrocntérologie, Hôpital Edouard-Herriot, Lyon; Inserm, U-49, and Chaire de Clinique Médicale A, Hôpital Pontchaillou, Rennes
Key Words. a-Fetoprotein • Radioimmunoassay • Hemochromatosis • Hepatoma • Liver cirrhosis Abstract. The serum a-fetoprotein level was measured by radioimmunoassay in 200 patients when admitted to hospital, 63 with idiopathic hemochromatosis and 137 with liver cirrhosis. In addition, repeated controls were performed in 19 subjects of each group for a mean period of 11 months (range 3-18 months). Elevated a-fetoprotcin levels were ob served initially or during the study period in 15 patients, a malignant liver tumor being demonstrated in 12 of them. In 4 of these patients, the abnormal a-fetoprotein concentra tion was the clue to the diagnosis of an unsuspected malignant hepatoma, but in none of these cases could the tumor be resected. The present results indicate that screening the serum a-fetoprotein level may contribute to the detection of malignant hepatoma in highrisk clinical groups, but the practical interest of such screenings may keep limited until more efficient therapeutic methods are developed.
The development of a malignant hepatoma is recognized in 7—25% of pa tients with idiopathic hemochromatosis (10, 16, 29, 36). The incidence of this complication seems to be increasing (23), its occurrence being noted even after adequate iron depletion in treated patients (9, 15, 36). A malignant hepatoma is similarly observed in 3—27% of patients with liver cirrhosis (7, 12, 18, 28), the highest figures being recorded in post-hepatic cirrhosis (13, 24). Although prolonged survival has occasionally been observed in some un treated patients (11, 27), the tumor resection appears to be the most beneficial curative approach (6, 21). Because of the high rate of unoperable patients at the 1 Supported by Inserm CRL No. 74.5.079.04. J The skilful assistance of Mrs. C. Bernard is gratefully acknowledged.
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Received; December 30, 1976; accepted; April 26, 1977.
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Table I. Patients studied Diagnostic
n
Idiopathic hemochromatosis Untreated Treated Iron-depleted Liver cirrhosis Alcoholic Posthepatic Cryptogenic
63 27 18 18 137 115 8 14
Male
Female
Age range years
55
8
28-66
100
37
25-81
time of diagnosis, early detection is compulsory if significant therapeutic results are to be expected. The diagnostic value of high serum a-fetoprotein (AFP) levels in human adults with malignant hepatoma has been thoroughly documented (34, 35). After the development of sensitive detection methods (30), it has become pos sible to recognise any increase of the serum AFP level above the normal range. The present study is an attempt to detect early malignant hepatomas in patients with idiopathic hemochromatosis and liver cirrhosis by using a radioim munoassay (RIA) for the measurement of serum AFP level.
Patients and Methods The study group included 200 patients, admitted in Rennes or Lyon from December 1974 to June 1976 (table I). Idiopathic Hemochromatosis This group included 63 subjects (8 females and 55 males, age range: 28-66 years). The diagnosis of idiopathic hemochromatosis was based on (a) the usual clinical and biological criteria; (b) the chemical measurement of liver-iron concentration in biopsy specimens (3), and (c) HLA typing (32). Among the 58 patients in whom the liver was histologically controlled, 30 had advanced cirrhosis, 16 definite but nonannular fibrosis, and 12 slight or absent fibrosis. The initial AFP control was performed before any treatment in 27 subjects, during the treatment in 18 patients, and after iron depletion in the 18 remaining subjects. Serial measurmeents of the serum AFP level could be performed in 19 patients, 63 blood samples being collected during a mean period of 10.2 months (range: 3 -1 8 months).
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Cirrhosis This group included 137 patients (100 males and 37 females, age range: 25-81 years). In these subjects, liver cirrhosis was demonstrated by biopsy (83 cases), peritoneoscopy without histological control (19 cases), or after the clinical and biological symptoms in the remaining patients whose condition was too severe to allow for the above investigations.
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Cirrhosis was attributed to chronic alcohol consumption in 115 patients, previous viral hepatitis in 8 subjects, while no precise etiology was recorded in the 14 other patients. In 87 cases, the clinical picture at the first AFP control included signs of decompensated cirrhosis. Serial measurements of the serum AFP level were performed in 19 patients, 81 samples being collected during a mean follow-up period of 12.0 months (range: 5 -1 8 months). Methods Sera were kept at - 20 °C until being assayed with a RIA method previously described (8), using a highly purified preparation of AFP from fetal serum as standard (Dr. P. Sizaret, 1ARC, Lyon). In this system, the upper limit of normal in adults (mean + 3 SD) is 7.7 ng/ml, equivalent to 6.61 IU of the 72/225 Reference preparation issued by WHO. AFP concentrations above this value were considered significantly elevated.
Results Idiopathic Hemochromatosis The initial control yielded two abnormal AFP concentrations in this group (table II). In patient 1, the development of a malignant hepatoma had already been suspected because of major hepatic enlargement, jaundice, and weight loss, and was subsequently confirmed at surgery. In contrast, the condition of patient 2 after repeated plilebotomies (15 liters of blood taken in 10 months) had not led to the hypothesis of liver neoplasia. The malignant hepatic tumor, demon strated thereafter at surgery was beyond any attempt of resection (table 111). In the 61 other subjects, the initial serum AFP concentration was normal. A malignant hepatic tumor was detected in 3 of them (patients 3—5). Patient 3, a 59-year-old man, with hemochromatosis iron-depleted since 3 years, had been given irregular injections of testosterone hexahydroxybenzoate for the last 5 years (total dose: more than 7 g). The postmortem control revealed a malignant hepatoma 9 months after completing the present study. Patient 4 had been maintained iron-depleted for the last 3 years, while a persistent iron overload was still demonstrable in patient 5, in whom the phlebotomies had been inter rupted 10 months earlier after a total blood depletion of 17 liters. No histologi cal control could be obtained in these 2 subjects. Repeated AFP controls in the 16 patients with normal serum levels and no detectable tumor when initiating the study, showed no rise of the serum AFP level in any of these patients, no liver tumor being demonstrated in this group during the study period.
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Cirrhosis When entering the study, 13 of the 137 patients with liver cirrhosis had elevated AFP levels. These subjects could be segregated in 2 groups: Group 1. A malignant hepatic tumor was demonstrated in 10 subjects (8 with alcoholic and 2 with posthepatic cirrhosis), the diagnosis of malignant
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hepatoma being histologically confirmed in 7 cases. In 8 of these patients, the neoplasia had been suspected before any control of the AFP level (patients 6—13). In the 2 other subjects, the high serum AFP concentration led to the diagnosis of the liver tumor (patients 14, 15; table II). Group 2. In the three other subjects, the rise of the serum AFP level was moderate (respectively, 13, 49 and 50 ng/ml). In none of them could any hepatic or extrahepatic tumor be demonstrated. Patient Sek., with alcoholic cirrhosis and histological features of superimposed alcoholic hepatitis at the time of initial control, could be followed up for several months. Among the 124 subjects with an initially normal AFP level, 2 patients had demonstrable hepatic tumors. In the first case (patient 16), the clue to the malignant hepatoma was the histological control of a skin metastasis. In the other patient (patient 17), a malignant liver tumor was demonstrated by scanning and peritoneoscopy after severe hypoglycemic attacks (table III). No Table II. Serum AFP levels in patients with recognized liver tumors Patient No.
Age
Sex
Underlying liver disease
Serum AFP level, ng/ml initial
1 2* 3
52 52 59
M M M
4 5 6 7 8 9 10 11 12 13 14* 15* 16 17 18*
56 66 64 51 77 63 72 67 65 70 64 62 67 67 60
M M M M M M M M M M M M M M M
untreated IH treated IH iron-depleted IH (+androgens) iron-depleted IH treated IH AC PHC AC AC AC AC AC AC PHC AC AC AC AC
delay
___ 3,550 2 months 11,500 7.3 10 months
1.3 4.1 157 26,000 9,500 2,010 3,650 6,600 44,500 75,900 160 42,000 6.2 8.3 6.0
subsequent
_
20,000 28
-
-
-
-
-
4 months — -
2 months
-
19,000 -
38,500
—
-
—
-
—
1 month
-
8,200
—
-
—
-
—
6 months 8 months
-
225 815
Nature of hepatic tumor
Evolution
MH MLT
MLT MLT MH MCH MCH MLT MCH MLT MLT MH MH MH MH MLT
deceased deceased deceased (1977J deceased alive deceased deceased deceased deceased deceased deceased deceased deceased deceased deceased deceased deceased
MLT
lost
MH
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IH = Idiopathic hemochromatosis; AC = alcoholic cirrhosis; PHC = posthepatic cirrhosis; MH = malignant hepatoma; MCH = malignant cholangiohepatoma; MLT = malignant liver tumor, no histological control; + = diagnosis obtained from serum AFP level.
Table III. Clinical and investigative details of the 18 patients with liver tumor, listed as in table II Liver scan Pro thrombin time, % (N 80%)
Hepatic angiography
Macroscopy5
Pathology5
Weight loss'
Jaundice Ascites
Alkaline phosphatase mlU/ml (N 30 mlU/ml)
1
+++
+
+
135
77
2
0
0
0
25
100
filling defect displacement of tumor left lobe celiac axis + peritoneum left lobe (LT)
3
++
0
0
13
100
filling defect displacement of tumor right hepatic arteries lobe (LT) right lobe + vascular tumor
4
++
+
+
107
77
5
++
+
0
192
100
multiple filling defects
6
++
0
0
80
100
filling defect left lobe
7
++
0
+
176
100
filling defect abnormal left left lobe hepatic artery
multiple hemorrhagic nodules (PS)
cholangiohepatoma (PMB)
8
+
+
+
69
52
filling defect right lobe
tumor right lobe (N)
cholangiohepatoma
filling defect displacement of irregular right lobe hepatic arteries hepatomegaly (LT)
Miscellaneous
differentiated hepatoma (WB)
differentiated hepatoma (PMB) recent hepatomegaly, hepatic murmur, death 2 days after admission recent hepatomegaly, hepatic murmur, no extrahepatic tumor found differentiated hepatoma (NB) Australia antigen +
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Patient No.
9
+++
+
+
85
77
filling defect right lobe
no extrahepatic tumor found
10
+++
0
0
55
70
filling defect right lobe
11
+++
+
+
28
60
hypervascular tumor left lobe (PS)
12
++
+
0
79
90
hypervascular tumor right lobe + hemoperitoneum (PS)
13
0
+
0
34
100
14
0
0
0
85
55
15
0
0
0
66
75
16
0
0
+
33
65
17
++
0
+
103
77
filling defect right lobe
whitish hemorrhagic areas, right lobe (PS)
18
0
0
+
37
50
filling defect hypervascular right lobe nodule right lobe
hypervascular nodule right lobe (PS)
tumor right lobe (PS)
cholangiohepatoma (PMB) hemorrhagic ascites
multiple nodules right lobe (PS)
right pleural differentiated hepatoma (NB) effusion
filling defect right lobe
no tumor seen (PS)
hepatoma (NB) Australia antigen +
filling defect right lobe
tumor right lobe (PS)
hepatoma (NB) splenorenal + hemosiderosis shunt, 1969 poorly differentiated hepatoma (skin metastasis)
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' + = 5 kg; ++ = 6 -1 0 kg; +++ = 10 kg.
1 N = Necropsy; L = laparotomy; PS = peritoneoscopy. 3 WB = Wedge biopsy: PMB = postmortem biopsy; NB = needle biopsy.
hypoglycemia; no extrahepatic tumor found
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histological control of the liver tumor could be obtained, but the search for a primary extrahepatic neoplasm was negative. Among the 19 patients followed up for several months, 17 kept a normal AFP concentration while no hepatic tumor was detected. High AFP concen trations were observed in the 2 other patients. Patient Sek. kept a persistently abnormal AFP level (between 13 and 160ng/ml), but no liver tumor could be found after various investigations, including angiography, peritoneoscopy and liver biopsy. The second patient (patient 18), a 60-year-old man with alcoholic cirrhosis had, initially, a normal AFP level. The concentration rose to 225 and 815 ng/ml, respectively, after 6 and 8 months of follow-up. A malignant hepatic tumor of the right lobe was then demonstrated by angiography and perito neoscopy, no biopsy being attempted because of the vessels on the surface. The condition of the patient deteriorated rapidly thereafter, and no resection was possible.
Because grossly increased AFP synthesis occurs in a significant number of adult patients with a malignant hepatoma, immunodiffusion methods are of value for the detection (34, 35) and the postoperative follow-up of patients with this tumor (1). These methods could be used as well for the screening of symptomless subjects, in order to detect early malignant hepatomas (17). The practical interest of such studies was, however, limited because of the lack of sensitivity of immunodiffusion. With tire more sensitive radioimmunoassay methods, high serum AFP con centrations are recorded in 70-100% of patients with malignant hepatomas (4, 8, 31), while the range of AFP levels observed in normal adult subjects is relatively narrow. In addition, AFP concentration appears to be stable with time (8, 25). Sensitive methods may thus be expected to allow for improved detection of these tumors. This was recently confirmed in two large study groups of patients with liver cirrhosis, where the control of AFP level was used alone or in conjunction with other investigative methods (19, 20, 37). However, the actual contribution of AFP screening to the detection, hence to the manage ment of malignant hepatoma in high-risk clinical groups is not fully assessed yet. The present work, though based on a relatively small number of patients, was an attempt to evaluate this contribution. In patients with idiopathic hemochromatosis or liver cirrhosis an abnormal AFP level cannot be taken as a proof for a malignant hepatoma. Elevated AFP concentrations have been reported in patients with these conditions (5, 8, 26) and no demonstrable hepatic or extrahepatic tumor at postmortem. The incidence of such variations was remarkably high in some series (14, 19). In most
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Discussion
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of these patients, the rise of AFP concentration is moderate and of relatively short duration, so that tire dynamics of the variation of the AFP level might help to differentiate the patients with malignant hepatomas from those without tumor. This, however, would result in a significant delay for the diagnosis of the tumor, if any. It thus seems that for practical purposes, any significant rise of the AFP level should instead be taken as a sign for a possible liver tumor (patient 18). In the present study, only 3 patients with liver cirrhosis had moderately high AFP concentrations and no demonstrable hepatic tumor, while none of the subjects with hemochromatosis fell in this situation. In contrast, a malignant hepatic tumor was detected in the 13 other subjects with liver cirrhosis or hemochromatosis and an increased AFP concentration. The incidence of proven malignant hepatomas in the liver cirrhosis group (5.8%) was slightly higher than the figure in the patients with hemochromatosis (3.2%). This is likely to have resulted from different screening conditions, since a number of patients with hemochromatosis were investigated through family enquiries, while most of the subjects with liver cirrhosis were in-patients admitted for clinical symptoms. Previous studies have demonstrated that a significant contribution to the diagnosis of hepatoma may result from AFP screening in high-risk clinical groups (19, 20, 37). This was confirmed in the present study, since the measurement of serum AFP level led to the recognition of an unsuspected liver tumor in 4 patients (2% of the total study group). Whether improved detection of these tumors through biological controls allows for better therapeutic results may, however, be debated at the moment. Significant results were obtained in some studies (27), while the improvement in therapy was low (17) or not indicated (19) in other studies. None of the present subjects with a malignant hepatoma detected before obvious clinical signs could benefit from a resection, because of severe underlying hepatocellular failure or neoplastic diffusion. Although the surgical management of malignant hepatoma has been clearly improved during the last years (6, 21, 22), curative resection keeps restricted to localized tumors in patients with a moderate liver cirrhosis (2, 22). Until new therapeutic methods are developed for the management of malignant hepatoma whatever the tumor spread and the degree of hepatocellular impairment, AFP screening appears to be mostly valuable for the diagnosis of localized AFP-producing tumors in patients with adequately treated idiopathic hemochromatosis or with liver cirrhosis and mild hepatocellular dysfunction.
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J.A.P. Chayvialle, Inserm, U-45, Pavillon H Bis, Hôpital Edouard-Herriot, 69374 Lyon Cedex 2 (France)
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